Tapering off Buprenorphine or Suboxone, Pt 2

In the last post we discussed some of the misconceptions about tapering off opioids.  Today we will discuss a couple basic principles, and then describe the approach I recommend for my patients tapering off buprenorphine.
Opioids act at receptors that normally bind endorphins, which are released by neurons in response to a range of stimuli including trauma and rewarding behaviors such as eating a good meal or using addictive drugs.  Endorphin pathways elevate mood, reduce sensation of pain, and impact urine production, immune function, intestinal motility, and other bodily functions.  Endorphin pathways have a certain baseline activity or ‘opioid tone’ that is directly related to opioid tolerance.   When opioid stimulation is greater than one’s tolerance, opioid tone is increased.  When opioid stimulation drops below one’s tolerance, opioid tone is reduced, causing withdrawal symptoms.

The goal of any taper off opioids is to recover original or native opioid tolerance.  Some people focus on getting rid of the opioid, and even use substances or behaviors to ‘flush buprenorphine from the body’.   Products marketed as detox agents have minimal impact on the clearance of buprenorphine or other substances.  And even if they could increase the rate of clearance,  they would only make detox harder by increasing the severity of withdrawal symptoms.  The relatively slow metabolism and clearance of buprenorphine provides a cushion by slowing the loss of opioid tone.

Prolonged use of any opioid changes opioid receptors.   The changes are not fully understood but include a decrease in number of receptors and changes in binding properties that reduce receptor sensitivity to opioids, including endogenous opioids (endorphins).  Recovery from a state of tolerance takes 2-3 months, and is initiated by reduced opioid tone.  Withdrawal symptoms reflect the reduced opioid tone that provokes eventual recovery of native tolerance.

Recovery of native tolerance is the rate-limiting step when tapering off any opioid, including buprenorphine.  When the dose of buprenorphine is reduced, the amount of buprenorphine at opioid receptors decreases over the next 5 days and then stabilizes at a lower level.  In response, opioid tone (the summation of current flow through opioid receptors) drops below normal.   If the dose of buprenorphine is maintained at that level, opioid tone will recover to normal in about 2-3 months.  If buprenorphine is suddenly and completely discontinued, opioid tone will decrease to very low levels and cause severe withdrawal that lasts for 2-3 months.  If buprenorphine dose decreases more slowly, opioid tone will decrease more slowly, lessening the severity of withdrawal.  But it still takes 2-3 months for opioid tone to return to normal.  So for any taper, patients must decide whether to decrease their dose quickly and be done in 2-3 months, at the cost of greater withdrawal, or instead to taper more slowly to reduce the severity of withdrawal.

The relationship between buprenorphine dose and opioid activity is linear up to about 2-6 mg.  Beyond that point further increases in dose have less impact on opioid tone.   The reverse occurs when tapering, so that opioid tone decreases only slightly as dose is reduced from 16 mg per day to 4 mg per day.  The non-linear dose/response relationship allows for rapid decreases in dose early in the taper process with limited or no physical withdrawal symptoms. Since the early challenge is mostly psychological, I use the early part of a taper to help assess whether a patient is truly ready to take on the tapering process.

I like to have patients lead the way in tapering off buprenorphine.  I’ve found that if I lead and reduce the amount of prescribed buprenorphine for the next month, patients often fail to make reductions and end up out of medication before the end of the month.  So instead I ask patients to tell me when they are certain that they are ready to stay at the lower dose.
During a taper, I recommend dosing buprenorphine twice per day.  Patients start by removing 2 mg from the evening dose.    After at least two weeks 2 mg can be removed from the morning dose.  This sequence is repeated at intervals of at least 2 weeks until the total dose is 4 mg per day. In my experience patients who get to that point are usually in a good mental position to begin the second, more difficult part of the taper.

Most people will be able to continue working when opioid dose is reduced by 5% or less every 2 weeks, or 10% every month.  That number is a good general guideline when deciding how fast to taper.  Suboxone film makes tapering relatively easy.  Patients purchase a weekly med organizer, and start the week by opening and stacking 7 films.  A scissors or razor is used to cut a millimeter from the end of the stack, and one film is placed in each compartment of the organizer for that day’s dose.  When the patient is comfortable with that dose, slightly more is removed for the next week.  The process continues every 2-4 weeks, eventually changing to the 2 mg films.  I recommend that patients continue tapering until the dose is 300 micrograms (0.3 mg) per day or less before stopping buprenorphine completely.  It is fairly easy to guesstimate where to cut the film in order to reduce by 10%;  just measure half, then half of that, then half of that.

Buprenorphine tablets, of course, are much harder to divide.  Zubsolv did people a favor by coming out with a range of doses, and hopefully other brand and generic manufacturers will eventually follow suit. For now I usually have patients use the tablets to taper as far as possible, using the 2 mg tablets in the lower dose range, and then pay the extra cost for the film for the final month or so.   A 12 mg film can be divided into 24 half-milligram pieces without too much effort, so the cost doesn’t have to be prohibitive.

I have had many patients taper successfully off buprenorphine.  Fear is common and normal for a number of reasons, but the fear usually gives way to a sense of confidence and optimism when a taper is done correctly.
Things to keep in mind:

  • Be patient.  Tapering by too much, or too quickly, causes withdrawal symptoms that lead to ‘yo-yos’ in dose.
  • Buprenorphine products are very potent.  A sliver of Suboxone Film may contain enough buprenorphine to harm or kill an animal or small child.  Take care to divide the medication in a well-lit setting, and clean up very carefully.
  • Buprenorphine is used to treat pain in microgram doses.  If you jump from 1 mg, you will have considerable withdrawal symptoms.
  • If you are still running out of medication early, it is not time to taper off the medication.
  • People on buprenorphine for a year or less have rates of relapse over 90%.  In my experience patients are more successful tapering off buprenorphine if they have been on the medication for 2-5 years or more.
  • If you struggle in tapering down to 8 mg, consider going back to your stable dose, waiting 6 months, and trying again.
  • People addicted to opioids often substitute other drugs for their drug of choice.  Do not start a new addictive substance in order to get off buprenorphine.

Good luck!

Missing the Point of Buprenorphine Treatment

A forum reader wrote about concerns over a partner on buprenorphine.  Her concerns pointed out a common misperception about the goals of treatment of opioid use disorder using buprenorphine, or using methadone for that matter.
Her question, amended for privacy:
I married the love of my life.  He is still he love of my life but has been an addict for 15 of them. Our children have been greatly affected by his addiction.  He made promise after promise that he was clean, and I dove back in with complete faith time after time only to get burned.
His addiction started with recreational pills increasing over time, but now he is abusing Suboxone.   He was taking up to 12 mg depending on the day, but no pain pills for the last year. I suggested a Suboxone doctor and a plan to get off, and my husband called one and was able to get right in.
At the visit the doctor did a half ass intake and called in a prescription for an 8 mg tab for induction.   After induction they called in prescription for 20 mg/day.   My husband stayed with 4 mg once a day and was “blah” in the afternoon and irritable but not physically sick.  On his next visit to the doctor he was proud, but when he told the doctor he had only take 4mg in the mornings she got angry. She told him she wouldn’t see him anymore if that’s what he was going to do. He asked how long he would be on it and she wouldn’t give any kind of answer. I asked again before we left and she snapped at me.
I see a profound change in him after each time we see her and she tells him to take more. We walked away last time with another prescription for 16 mg a day which is just about double what he’s been taking for the last year and a half. So my question is, how does it make sense to treat someone taking 8 mg as their addiction with the same medication at double the dosage? Since seeing her he has decided he needs to take it more than once a day as well as up the dosage.  Is this right? Is it right to treat Suboxone addiction with Suboxone? A heroin addict isn’t treated with more heroin and a pill addict isn’t treated with more pills.  While I understand the concept of treating his original pill addiction with Suboxone, I am having a very hard time wrapping my head around what’s happening.
Me again… 
The writer raises interesting questions.  Regarding the ‘drug for a drug’ questions, buprenorphine has significant pharmacologic differences from heroin or pain pills. Those differences, including the long half-life and ceiling on agonist effects, allow the medication to create a level degree of mu-receptor agonism across the dosing interval.  Tolerance to that level mu agonism allows patients on the medication to feel ‘normal’ throughout the day, or at least normal from an opioid standpoint.
But her broader point provides an example of the basic misunderstanding many people have about medication assisted treatment, in focusing on the same short-term goals that their addicted loved ones have focused on: controlling the dose of opioid and tapering off.  That goal is natural, of course;  anyone who loves a person addicted to opioids wishes and hopes that the person will reverse the using behavior and climb down from opioid use.  Those hopes are bolstered by ads for rapid detox, even as studies show that detox is mostly useless.
My response:
I would not be concerned about increasing the dose of buprenorphine, because there is no increase in effect after a dose of about 8 mg per day.  A higher dose might reduce mild withdrawal symptoms at the end of the dosing interval, and sometimes provides a reduction in cravings through a placebo effect.
So why increase? Because the goal with buprenorphine treatment is to put cravings into remission for a considerable length of time. If your husband is still having cravings as he gets by on 8 mg, then his dose is not high enough. Buprenorphine is a safe medication that is used as a tool to extinguish the conditioning that was part of your husband’s addiction.
One of my patients saw a different buprenorphine physician for years, and her dose was constantly lowered over the past year. She would run out of medication after 24 days each month and then go without for 6 days, craving opioids and experiencing wtihdrawal during that time.  In some ways, her entire time in treatment was a waste.  She could boast, I suppose, that she was prescribed less buprenorphine over time. But in most ways she is just as far from stopping opioids as when she entered treatment, still lying to her husband, lying to her doctor, and feeling ashamed of herself.   All of those things  keep her addiction in the dark, where it stays active.
When I started treating her my goal was to promote legitimate behavior. I increased her dose to 12 mg per day, from 8 mg.   After a month she still ran out early, So I raised the dose to 24 mg per day. Now, after 6 months, she has taken the medication as prescribed. Her focus on buprenorphine is going down, as we want it to do. She isn’t lying, and she isn’t craving pain pills or buprenorphine. My goal is for her to take the medication like she would take a vitamin or blood pressure pill, without any special attention or interest.
How long will we do this? I can’t say now. We know from research that the longer a person stays on medication, the less risk of relapse after stopping. I don’t like to push anyone off buprenorphine, because I’ve seen so many people who have relapsed after being pushed off by their former doctors.  I find that many people eventually decide that the time has come to taper off buprenorphine, and those efforts are usually successful.  From my perspective, people forced to taper off buprenorphine do not generally do well.  That perspective is just an opinion, but an opinion based on treating 800 people with buprenorphine over the past 11 years.
Opinions aside, the goal is not about getting off opioids as fast as possible. Your husband can accomplish that in a couple weeks with a remote hotel room and a bottle of clonidine, or a couple weeks in jail. But those experiences rarely lead to prolonged abstinence, and they sometimes precede overdose, when people return to using with a lower tolerance.
I can’t tell whether your husband’s doc is on the right track or not– but she might be. She is a better doctor telling you that she can’t give a time estimate, than a doctor telling you he will be off in 3 months.  Ideally, your husband will be in a state of ‘remission’– on a dose of buprenorphine that virtually eliminates interest in opioids– for a year or more. He can taper for some of that time, but the taper should be slow enough that he doesn’t return to using.  If he returns to active use, he starts over in many ways.
Try to drop the focus on ‘how much’ or ‘how long’. Those things are not important; what is important is to get his interest back on you and the family, not on buprenorphine or other opioids. That will be easier if you let him know that he has your support, even if he takes a medication, and even if he needs that medication for a long time. You would want the same from him if you ever needed a medication for hypertension, diabetes, or anything else.

Addicted to Suboxone

First Published 7/23/2013
I hear from the anti-buprenorphine people now and then, less than I used to.  I also hear from fans of this blog’s early days, when I routinely lost my temper in response to those people.  Their general line was that things on heroin weren’t all that bad, but now, on buprenorphine, things are miserable.  Starting buprenorphine somehow removed an opportunity to be clean that they used to have, that they would have used if not for buprenorphine.
They somehow miss the obvious—that they could ALWAYS go back to the heroin addiction that worked so well for them.  They’ll say they could stop heroin any time they wanted (you know the joke—‘It is so easy to quit that I quit a hundred times!’), but act as if someone is forcing them to take buprenorphine.
If it is so easy to stop heroin, why not go back to heroin and stop?
For the record, I don’t advise people on buprenorphine to change to heroin.  It is difficult to wean off any opioid, including buprenorphine.  But I do have patients who have tapered off buprenorphine; something I’ve never witnessed with agonists like oxycodone or heroin (i.e. tapering outside of a controlled environment).    Most people who read my blog know that I don’t recommend tapering off buprenorphine for most people, an opinion I’ve come to after seeing many people relapse, and some people die, after stopping buprenorphine.
I received a typical anti-bupe message yesterday; the message and my response are below.  There are a few typos that I can’t decipher….
Errors of logic, anyone?
Subutex was the worst mistake I ever made. I was an off and on heroin user for 5 years. I was clean for over a year and relapsed that when I survived Subutex first I was getting it off the streets then my wife ego had the insurance got a script. She was pregnant so the doctor prescribed Subutex. She told her that her brain would never be the same from her opiate use and would need Subutex most likely for the rest of her life. We both were quickly using it IV IT killed our sex life. It made me feel like a woman or something I have no libido at all. I quit using it IV for 9 months then started again which caused me to have a full blown relapse I’m in 12 step recovery. I lost our home shortly after our new born son was born forcing her to move in with her parents and I moved into an sober living house. We are now both trying to taper off this drug that it’s overly prescribed. The doctor put her on 26mg a day mind you we shared but the doctor doesn’t know that. I do believe in short term low dose setting this drug has a therapeutic value. But I believe it’s been designed to get money lost to drug dealers into the pockets of our government. I kicked Heroin and Oxycontin more then once. Getting off Subutex has been the toughest one yet the physical and mental withdraws are horrible. The best bet for addiction treatment is 12 step meetings. All Subutex or Suboxone does is give you a crutch and prolongs actual recovery from the disease of addiction. They don’t tell you about all the terrible side effects behind this medication its marketed as a miracle drug. A wise man once said if it sounds too good to be true then it’s probably not. Rant done hopefully this helps someone. The answer to recovery is the 12 and staying sober 1 day at a time, most important a relationship with a higher power.
My Response:
An interesting comment… You’ve taken heroin for over five years as an ‘off and on user’.  You then illegally obtained buprenorphine, and injected it (!)… illegally shared what a physician prescribed for your wife… but it’s all buprenorphine’s fault that you are experiencing problems?  Part of the 12 steps that you favor includes taking responsibility for what happens in one’s life, yet I don’t hear a lot of that in your narrative.
I don’t know about ‘miracle drug’, although it probably has saved the lives of both you and your wife, since IV heroin addicts don’t tend to do well beyond 5 years.  There is nothing in your history to suggest that your ‘on and off use of heroin’ would have somehow come to an end, had you not changed your drug of choice to buprenorphine.  But one aspect of buprenorphine is the ‘ceiling effect’, which makes overdose much less likely.
Likewise, I don’t see a government conspiracy, and I disagree with your comment about ‘low dose use’.  Buprenorphine HAS been used in low dosage for treating pain for the past 30 years, but everything about buprenorphine that makes it a good addiction treatment relies on the person taking a dose that assures a high blood level, i.e. above the ceiling level for the drug’s effects.  In low doses, buprenorphine acts like any other agonist– i.e. causes the same up/down mood, cravings, and obsessive use pattern.
Your problem is that you became addicted to opioids, and your opioid addiction has cost you a great deal.  You misused buprenorphine by injecting it, but luckily for you the drug has certain safety features that helped keep you from overdosing– something heroin doesn’t have.    But now you blame buprenorphine for all your problems.
I certainly do not suggest that you do this, but for the sake of making a point—-  you could easily go right back to where you were, before you met buprenorphine, if you returned to your addiction to IV heroin.    If you started heroin tomorrow, the buprenorphine would be out of your system in a week or so, and… voila….. you would be ‘cured’ from this horrible affliction that you claim to have, i.e. an addiction to buprenorphine.  Or are you going to suggest that taking sublingual buprenorphine was somehow WORSE for you than doing what you were doing before finding a doctor, when you were injecting foul solutions of heroin into your veins?!  You were FINE with the heroin, but BUPRENORPHINE has ruined your life?
Sorry– I don’t buy it.  Most people who stop ANY opioid– buprenorphine, oxycodone, or heroin— end up using again.  Buprenorphine, as a partial agonist, relieves cravings in a way that opioid agonists can’t.  And taking buprenorphine certainly doesn’t make anything ‘worse’;  a person addicted to heroin, who doesn’t like taking buprenorphine, can always go back to heroin!  I don’t recommend it, as the overdose risk is very high with heroin, and people on heroin suffer from constant obsessions to take more and more– a life far worse than the person properly taking buprenorphine.
This is where I come in… THESE are the patients I see on a regular basis.  The doctors who used to call them ‘good patients’ now call the same people ‘drug addicts.’  And the pain doctors—the ones who create so many addicts—give lectures on ‘how to prescribe opioids.’   I can spare you the need to attend the lecture— the main message is that after you make the patient an addict, you must do everything that you can to separate yourself from the patient before the consequences of that addiction become apparent—so that your hands appear sparkly-clean!

Withdrawal from Suboxone or Buprenorphine

I received a question from a reader about withdrawal symptoms from stopping buprenorphine. My answer has relevance to opioid withdrawal in general, and to a common misconception about the duration of withdrawal symptoms.
The message:
Basically I quit Suboxone about 18 days ago. When I decided to quit I was taking about 8 to 12mgs per day. I got into taking Suboxone from trying to quit a Percocet habit that developed after a car wreck. I was stuck on Suboxone for near 3 years before I finally realized the person I thought I was really wasn’t the person I expected myself to become. So I decided I had enough and quitting Suboxone should be easier than quitting Percocet. I still laugh over that because I should have educated myself better before I landed myself where I am now. I am starting to feel marginally better but I have zero energy and my depression is off the charts. . . My question is because Suboxone has such a strong half-life being a partial instead of full agonist, how many more days weeks months do I have to suffer through before I can expect to return to normal? I am terrified of relapsing and have set a zero tolerance for myself. Hopefully I am strong enough and smart enough to stay away but is there anything extra I can do to help ease anxiety and the depression? Honestly I feel like I live in a personal hell no one gets or understands. I was just hoping u could give me some advice. Thanks for reading my message.
My answer:
There are many misconceptions about withdrawal and buprenorphine. Many people make the mistake of thinking that the long half-life of Suboxone lengthens withdrawal. The long half-life of buprenorphine reduces the intensity of withdrawal, but has a very minor effect on the duration of withdrawal symptoms.
Before going there, though, I’ll comment about where you are, and where you came from. I admit to feeling a bit annoyed when people write about being ‘stuck on Suboxone.’ I’m not sure why it bothers me as much as it does; I don’t receive kickbacks from Reckitt Benckiser, and I certainly had no part in inventing Suboxone. If I put words on my annoyance, it would be something about looking a gift horse in the mouth—a saying that nobody seems to say anymore.
Suboxone didn’t cause your problems; YOU caused your problems, or perhaps Percocet did. Suboxone bailed you out; it allowed you to live to fight another day, rather than go down the tubes and end up in prison or dead, from oxycodone addiction. People often write the same thing— about being stuck– on my forum, and I have the same reaction there. It seems to be so unappreciative or irresponsible, to blame the very thing that kept you alive.
For the people who write ‘I should have just stopped oxycodone without taking Suboxone’, I point out that it is clearly easier to stop Suboxone than oxycodone. How do I know? I know because we are having a discussion about tapering Suboxone! Nobody addicted to opioids tapers off oxycodone (everyone tries, but nobody is successful). At least SOME people CAN taper off Suboxone. Don’t believe me? Think it would have been easier to taper off oxycodone? Then you can just change to oxycodone and get on with the taper! NOTE—I do NOT recommend doing so; oxycodone is MUCH more addictive than buprenorphine, and much more likely to kill you!
The other reason the attitude bothers me is because after treating people addicted to opioids for the past 7 years, I’ve watched so many people from utter despair to stabilized on Suboxone, and then become convinced that they aren’t ‘clean enough’ on Suboxone. I’ve watched them taper off, and I’ve seen their obituaries a few years later, or received desperate emails describing the loss of a 70 K per year job because of a recent felony conviction. Meanwhile I have a number of patients who are content to treat their addiction for years, as their lives get far better than they ever dreamed.
For those still reading, I’ll explain why half-life is not a big contributor to the duration of withdrawal. If we took any person on any opiate, then suddenly and completely removed the opiate from the body, the brain pathways that are stimulated by opiates (the endorphin pathways) would suddenly become quiet. As those pathways stop firing, the person feels horrible. After all, the pathways help keep everyday-sensations from being painful and help elevate mood, so the opposite happens when they stop.
As the person used higher and higher doses of opioids over time, tolerance developed at the receptor level. In essence, the receptor for opioids became less sensitive to ALL opioids. Receptors that are not sensitive to oxycodone, are also not sensitive to hydrocodone, and not sensitive to the brain’s own opioids—endorphins. In a withdrawing person, there is little or no activity in opioid pathways because the receptors, where endorphins usually act, are no longer responding to endorphins.
In order for withdrawal to end, the body must make NEW receptors, and implant the receptors in the cell membrane. That takes weeks to occur. The process is initiated by withdrawal itself. When the neurons in endorphin pathways are not firing at their normal rate, the neurons respond to that lack of firing by turning on the machinery involved in making new receptors. In other words, the pain of withdrawal MUST occur, if receptor renewal is to be triggered.
The duration of withdrawal is a function of how long the body takes to make new receptors– NOT the amount of time to clear the body of the substance. Some people mistakenly think that withdrawal ends when the drug is gone– and that it is ‘stuck in the bones’ or things like that. All of that makes interesting reading, but it is not what is going on. It takes 8-12 weeks for the body to make new receptors, so that is how long opiate withdrawal usually lasts.
Suboxone DOES have a long half-life. That long half-life causes the initial withdrawal to be less severe because instead of turning off instantly, the opioid pathways become less and less active over days. So instead of the sudden onset of severe symptoms, the misery takes several days to peak. This may result in the entire process lasting an extra day or two, but that extra time is not relevant compared to the weeks that it takes to generate new receptors.
I imagine that people get different impressions of withdrawal because of the different patterns of misery from different opioids. When I came off fentanyl, I was very, very sick for the first few days. I could not walk, literally, and my systolic blood pressure never got above 90. A week later, I could walk, and so things seemed a lot better. But I still got winded after 20 feet, and I couldn’t eat for many weeks. I lost 30 pounds in the process, and I was skinny to start! Buprenorphine withdrawal starts more slowly, but then ramps up higher after a few days, and then slowly goes down. I see people come off all sorts of opioids; the pattern of misery varies, but the total misery is about the same in each case.
Specific to the writer, one should anticipate 2-3 months of fatigue and loss of appetite after stopping buprenorphine, similar to other opioids. The first few days are a bit less severe with buprenorphine than with, say, oxycodone, because the drug is leaving the body more gradually.
A final comment—I worry whenever I read that a person’s strategy for staying sober involves being ‘smart’ or ‘strong’. The only way I know to stop opioids is by coming to the full realization of one’s powerlessness over them, as in the first step of AA/NA. Being too strong or smart only gets in the way of that realization. In my opinion fear is the best approach, as in ‘if I try, even once, I will die— and it will ALWAYS be that way.’
I wish you well,
J

Withdrawal from Suboxone

I often receive e-mails asking for advice on tapering Suboxone, or asking how long Suboxone withdrawal should last.  People who read my blog know my approach to stopping Suboxone; I see it as an exercise in futility even in the rare cases where the person is successful, because of a relapse rate that verges on 100%.
A couple myths to get out of the way… there is NO evidence that withdrawal becomes more difficult the longer a person is on buprenorphine.  In fact, from my experience the opposite is true.  The feelings and emotions during withdrawal are aggravated by the guilt and shame of active using, and the further from active using a person gets, the less the suffering during withdrawal—and the better able the person is to keep some perspective on what is happening, rather than drowning in despair.  I believe that the severity of withdrawal is subject to a ‘kindling effect’, a phenomenon that affects seizure disorders and other neural activity as well.  In other words, the pathways of the brain that are used the most frequently are the pathways that are most likely to fire again.  So a person who has been through very severe withdrawal is likely to experience withdrawal as very severe, no matter what agent the person is stopping.  It would make sense that the more time that goes by in between episodes of withdrawal, the less powerful would be the kindling effect—sort of like ruts in a muddy road being erased by repeated cycles of weather over time.
Many people write on blogs or forums that Suboxone withdrawal is worse than coming off opioid agonists.  This is simply ‘poppycock!’  I have seen many, many people go through opioid withdrawal, and have experienced it myself (gratefully, many years ago!).  People going through withdrawal from agonists are very miserable; they tend to stay in bed, getting up only to race to the bathroom because of severe diarrhea.  Their legs shake involuntarily—a very uncomfortable experience that is similar to severe ‘restless legs.’  The mental effects are perhaps the worst; most people have severe depression and thoughts of suicide.  Eventually, when the person attempts to get out of bed, he/she faces weeks of profound fatigue and weakness.  During my own detox ten years ago I remember my family visiting after a week or two, and being able to walk about half a block before needing to sit and catch my breath.  Appetite is gone for weeks as well, and most people lose significant weight during detox.
Withdrawal from buprenorphine, on the other hand, rarely forces addicts into bed for more than a day or two.  I’m not saying that they don’t FEEL like staying in bed, but they will still usually get to work and engage in the activities of daily living—eating, showering, getting dressed, etc.  A simple look at the forums shows a profound difference between Suboxone and agonist withdrawal; people coming off Suboxone write about how bad they are feeling, whereas people coming off agonists are nowhere to be found— and are certainly not able to sit at the computer and type!
There are two basic approaches to stopping Suboxone.  One is to taper slowly, and the other is to just ‘jump’ and handle the withdrawal as best as possible, sometimes with the help of clonidine, benzos, or other substances.  Some people find that THC helps, but I can’t really recommend that approach—at least not in states where there are no laws allowing the use of ‘medical marijuana.’  There are a couple taper methods described here and there on the web; I described something called the ‘liquid taper method’ on the forum that uses tiny doses of dissolved buprenorphine, administered by an eye dropper.  As I mentioned in an earlier post there is a new transdermal buprenorphine system hitting the market soon, and that should make things considerably easier.  The main problem with any taper is that the person usually gets to a certain point and then realizes that a full dose would cause a ‘buzz’—and that buzz is almost impossible to say ‘no’ to, especially after being in minor withdrawal for several days or weeks!  The transdermal approach is appealing because it would allow the person to get rid of all tablets that could be used to bail out of the taper.  I can’t imagine that there is much chance of success if the person has 8 mg of tablets stashed away in the house somewhere!
Because of the tendency to bail out of a taper, most people who start out tapering end up ‘jumping’ at some point—raising the question of whether people should just jump from the start, planning to be miserable for a good few weeks, and then just tolerating it.  For those taking that approach, the main thing is to STICK WITH IT.  In order for your receptors to return to normal, you MUST be miserable— that misery is what causes the neurons to manufacture new receptors.  If you take a break from the misery by using for a day, you turn off the forces that are moving you toward feeling better, delaying the process by days to weeks.  To be direct, the quickest way to stop Suboxone and get back to zero opioid tolerance is to avoid opioids completely until you feel better.
Again, in my opinion, all of this is folly because the chance of staying clean is low. At minimum, a person must be completely free of any contacts who are using or who have access to opioids.  The person should be actively involved in some time of recovery program.  The person should have someone in his or her life who can act as a ‘reality check’ to speak up if the person starts to harbor resentments, or if the ego begins to grow out of control.  If you don’t have these things at a minimum, consider just sticking on buprenorphine.  You will save yourself a great deal of money, time, embarrassment, and who knows what else.
If you do stop buprenorphine, expect withdrawal to peak at about 4-7 days after you finally discontinue taking Suboxone, followed by slow recovery that accelerates each week.  By four weeks, you will be done with the creepy crawly legs, and your energy will be starting to return.  By two months, your sleep should be coming back—unless you are also stuck on benzos, which make sleep a big problem if you use them for more than very short-term.
By three months, you should be back to normal—assuming that you did not use opioids at all.  And you will recover fastest if you get some exercise, eat right, and stay as active as possible, even when you don’t feel like it!

User's Guide to Suboxone

Many of you are familiar with my e-book, ‘User’s Guide to Suboxone,’ that has been available for sale on the web.  The copy that is sold through that site is ‘print-protected’ and copy protected;  a password is required to open the document and it cannot be printed– at least not without a bit of digital trickery. 

e-book about buprenorphine

I was just looking through the book, and realized that it ain’t that bad– I’m no Hemingway, but I think that it contains some good ideas, and the words are spelled correctly.   The chapters are listed at the end of this post.
I plan to upgrade ‘the forum’ in the near future, and part of that process includes raising money for a web designer.  My friend Jim will always be the ‘right-hand guy’ with the programming, but I can only ask for so much free help before feeling guilty!  So if anyone out there has considered making a donation, now is the time…. because a $5 donation will get you a copy of the e-book, User’s Guide to Suboxone, sent as an e-mail attachment that unlike prior forms can be printed.  I do ask that you respect the copyright, and if you want a dozen copies for your treatment center, send me a note to work out a discount– rather than simply making 11 copies.
Instead of automating things this time around, if you want a copy of the printable e-book I’ll have you use the donation button on the right side of this web site.  Just make a donation of $5 or more, and I will use the e-mail address that you use for the PayPal or Google Checkout donation to send the book as an attachment.  I’ll get it out within a day or two.  Proceeds will go to the new SuboxForum– the more I raise, the nicer I hope to make it!  As always, thank you all for your support.
List of Chapters:
A Caution
Introduction
Introducing Buprenorphine
Practical considerations
High Tolerance at Induction
Precipitated Withdrawal
Pain control
Surgery
Pregnancy
Length of Maintenance
Tapering
Other Medications While On Buprenorphine
Other Drugs of Abuse
Benzodiazepines
Other Medications
Buprenorphine Side Effects
Twelve Step Meetings
Future trends

Hard Knocks, Talwin, Tapering: Q and A from SuboxForum.com

A new feature on SuboxForum.com is the ‘Q and A,’ where I select a question to answer in detail.  I will post my answer here as well.  I won’t post the original question, but it is embedded in my response so I think everyone will figure it out!

There are really a number of questions in your post, so I will do my usual thing and answer them as we go through the message. As always, these are my opinions; consult your own doctor before changing anything about your dosing or medication.

The message/my responses:

Thanks. I feel obligated to pay, and will–but I’d rather pay when the time is right for me to go thru w/d off subs. My problems are more than just getting off this suboxone. I now know I need to be in better stable frame of mind to go through this—everything I read on the blogs says be prepared to go thru this weaning.

Donations are appreciated and helpful, but don’t feel obligated, please. If someone is comfortable helping to support my time here and the site in general, please consider a donation. If you are going through hard times, take care and don’t sweat it! Two comments though: First, as you know my ‘big thing’ is recommending people STAY on Suboxone. Yes, it is expensive—but not NEAR as expensive as using, even if things go well. Throw in unexpected consequences like an arrest and the costs really go up! But my second comment is to agree with you. If you want to taper off Suboxone, you need to start at a time when things are great—because the process takes a lot out of you.

Talwin made my chest tight and my legs felt weird. And I went into full W/D by the 3rd day off suboxone. It was last Sat so I called the after-hrs nurse and told her what happened. She contacted the Dr who had my RX avail within the hour. I was fine within minutes of taking 4mg. But I had a really hard time getting back on any dosing schedule all this last week. Is this psychosomatic or something? I mean relief was immediate.

It usually takes a few days for withdrawal from buprenorphine to become severe, due to the long half-life of the drug. Relief from resuming buprenorphine usually isn’t immediate, so some of the relief may have been psychologically based. The uptake starts at about 20 minutes and is pretty much complete at 90 minutes. I remember your other letter—you were recommended Talwin, of all things, to taper off Suboxone. That was poor advice. Talwin doesn’t even bind to mu receptors, which are the receptors that buprenorphine works through. Talwin contains naloxone and pentazocine, the latter is a kappa and sigma agonist, and we all know what naloxone does! The naloxone in Talwin would if anything make you more sick during your withdrawal; pentazocine is a nasty drug that has been abused in years gone by (combined with Ritalin, for example) and that can cause seizures, hallucinations, and other dysphoric states. I do not recommend using Talwin to taper off Suboxone.

I read so many horror stories online about others who quit at 2mg who suffered for months. When I first went on suboxone I was miserable and unable to function for at least 3full weeks–out of work a whole month. My Dr says that shouldn’t be. Well be or not it was. My back was killing me–all I could do was lay around on the couch and try to get up and move as much as possible–the terrible loss of clear vision/runny eyes and dilated pupils, goose bumps, achy all over–the only help the suboxone was fast on was the desire to take more Vicodin and the diarrhea stopped.

You don’t mention the dose of opioids that you were taking at the time that you started Suboxone. What you describe sounds like ‘precipitated withdrawal’—if your total daily dose of opiates was greater than 30 mg of methadone, or 50 mg of oxycodone, or 70-80 mg of hydrocodone, then I would expect you to feel sick when starting Suboxone—unless you went a few days without any opioids and got your tolerance down a bit.

If you say it shouldn’t take too long to wean off, then why are so many people having such a hard time and taking so long with so much misery to get off either the opioids or the suboxone? I got a taste of suboxone w/d last week and it was not pretty.

Opioid withdrawal stinks! No doubt about it. I am well aware of the complaints about Suboxone withdrawal, but I have witnessed withdrawal from buprenorphine and from agonists many times (and experienced it as well!) and I know the truth of the matter—that there is no comparison. Methadone withdrawal always lasts for months—always! Fentanyl, oxycodone, and heroin withdrawal are violent—legs kicking, diarrhea and nausea, extreme weakness… I often say that the reason you read about how bad Suboxone withdrawal is, is because those people 1. Can go off Suboxone, and 2. Can still function enough to write on the internet. Neither is the case with agonists– people cannot taper off, and if they are forced off they are not able to type messages about how they are feeling! I have argued this point with the people who post ‘Suboxone w/d is the worst ever’, and they insist they are correct. All I can say is that I have seen both many times. I do notice one thing to explain the discrepancy: people ALWAYS think that their current is their worst misery. Pain experienced is worse than pain remembered.

Is it really true that .5mg suboxone is as potent as 30mg hydrocodone or 10-20mg methadone?

The kinetics are not ‘linear’. So if taken in an optimal manner, 2 mg of buprenorphine is as potent as 4, 8, 12, 16, or 32 mg of buprenorphine. They all are at the ‘ceiling’ potency, and all are equal to about 30 mg of methadone, 50 mg of oxycodone, or 70 mg of hydrocodone. Your numbers are about right.

Have I been taking huge amts of narcotics (albeit diff than full receptor opioids) for 2years now? I read up on suboxone when I started, but then haven’t paid any attention since then—too much else going on. Now I’m freaked about going off of em if they really are equivalent to pretty high doses of opioids.

Again, you do not say what you were on before the buprenorphine. But yes, to some extent you are correct in your statement. I wouldn’t say ‘huge’ doses, but I would agree with ‘high’ doses. To put things into perspective, methadone clinics officially shoot to have addicts on at least 60 mg, but usually have them at 100 mg or more. Most oxy addicts I see take two 80’s per day or more— 160 mg of oxycodone at a minimum. The largest dose I have seen taken by an addict was 700 mg of oxycodone per day—she had inherited $300,000 and it was all gone after one year. So in comparison, 30 methadone-equivalents of a partial agonist is not ‘huge’, but it does represent significant opiate activity.

I now know I have to wean to less than 2mg a day to go off this stuff, and I am planning to set aside 3weeks from work to go through this. You say the worse thing to do is lay on the couch–keep moving. I’ll do whatever I can to make it better, but I cant go through last week again until I have time off from my frantic life! And my frantic life —no real sleep for 15months..isnt going to end until I get out from under my financial mess. So I will plan a good 3weeks minimum to get over this stuff.
And now I read about others that are weaning way way back to tiny slivers of subox to quit and still going through hell when they finally do.

Three weeks is not enough. But that is not the fault of Suboxone; three weeks isn’t enough to get off any opiate! I mean, REALLY! Look what you, and other people, are asking for! You haven’t mentioned what you took but some people will use for ten years… then go on a year or two of Suboxone, and if everything isn’t perfect in three weeks—THREE WEEKS!!!—they complain about Suboxone?! Talk about expecting miracles! Talk about expecting an easy way out!! My active using lasted several months—that was it!! I was in detox, sick as sh…, then in residential treatment… for 14 weeks!! I then was in aftercare for 6 years, going to AA several times per week, PLUS group therapy twice per week. And while I treated my addiction aggressively, there were and are many, many people who treat it as aggressively or more! In the place where I am medical director, we send many people to a year of living in a sober community—a halfway house, essentially—and that is AFTER six weeks in residential treatment and three months in a halfway house. And that amount of treatment, in my opinion, is a bit light!

I have to repeat this because people don’t seem to get it. I used for several months– Adding 1993 and the 2001 relapse together, my total opiate use was less than one year! And my treatment was 14 weeks in residential AFTER detox, then six more years of meetings and group therapy—THAT is how you get clean before the world of Suboxone!!

As for the ‘tiny slivers’… read about ‘micrograms’ on my blog so I don’t have to repeat it. Two mg is way to high to ‘jump’ from. The withdrawal from quitting two mg is about the same as the withdrawal from 16 mg, for reasons I mentioned above. One person on the forum is in the process of tapering down to the low micrograms and writing about it—he uses a technique I have written about (but that I didn’t invent—it was sent to me by a reader) where the buprenorphine is dissolved and taken with an eyedropper.

Do you not see that these people that are going through pure misery to get off of this stuff?

Yes—and I’m sorry, but I consider those people fools. Their lives were saved once—they might not be so lucky the next time. And for the vast majority, there WILL be a next time. That is just the fact of the matter. They all have the same fantasy—a fantasy I once shared—of being ‘normal’ again. It ain’t happenin’, folks. I’m sorry to break it to you. All the misery you are going through tapering off Suboxone… some day in a few years you will be saying to yourselves, ‘why the heck did I stop that med, when everything was going so well?!’

I found one plan that says to cut back 25pct for 4days and if no problems keep cutting back till it’s over. If I dont make it, take a sliver to stop the w/d then start that 4days over. I saw you have 2 tapes explaining your “tried and true” method to detox from subs…
I will order your tapes when I’m ready to go off the subs. ( I have 6weeks off starting Sept 1 this year)
.

My tapes aren’t magic, and the method isn’t ‘tried and true’. I don’t say that. I wouldn’t say that. It is very hard to taper off any opiate, INCLUDING SUBOXONE. My tapes describe what I have seen to work the best. I provide all of the same info as on the tapes in the blog itself—so if you have read through the blog, don’t worry about buying the tapes. I do try to give some extra motivational stuff, but the techniques, the meds, the ‘how to tell when you are ready’… I’m sure I have covered it in the blog itself by now. But if you want to save some time and provide me some support at the same time, by all means purchase a tape, with my thanks.

Right now I am facing extreme pressure having to sell my home and everything I own and quit my job of 31yrs and move back home to Iowa to live with my mom. I’m 54yrs old and have lost everything–even my credit. All cuz of a steady stream of bad luck (dont blame the drugs–I wasn’t on them till I was recovering from my last accident) It’s very humiliating and disheartening to work so hard and so long and then nothing worked out and I have to start over at my age.

I’m sorry for what you have been through. All the more reason, in my opinion, to keep the Suboxone going if you can get it paid for. Look into Medicaid. Ask the doc if his patent assistance plan is full (every doc gets a couple spots). You don’t need any more problems right now, so KEEP YOUR ADDICTION TREATED.
You got your pictures in the paper for being a hero (cool eh)…

Thanks for noticing—the high point in my life for sure. Posted on my site at wisconsinopiates.com.

I got mine in for bad luck (I just moved into a home I built myself and the next month it flooded–the local County bought it and tore it down-top story on local TV showing them bulldoze all my hard work down in about 8min. –then a frikkin tornado hit down and only damaged two homes–my two rental houses that are next to each other–the paper reported it as a freak tornado–we don’t have tornadoes in WA.) Then the injury accidents –fell off a rental house roof–then fell down a spiral staircase, then got rear-ended by a huge Ford Econoline that lost his breaks..Then fell fixing an awning on my new home up on a hill away from flooding rivers. But I got over it…I was doing great–my shoulder and neck surgeries were healing very well ….went on my first vacation in a long time and my brand new car hit a soft spot on a dirt road (the Idaho Sheriff called it a freak accident) and my car plummeted down a steep cliff and crashed into a tree that saved me from drowning in the river below—still got over that –but 9mo out of work forced me to refinance my home to a subprime because I was financially strapped being on a medical leave without pay—but I was determined to get back to work–I paid extra loan origination points to buy down this awful loan to 1year-no prepay penalties–and I worked very hard to have good credit so I’d refinance into a nice 30yr fixed in a year. But a year later I had no house to refinance.

A freak windstorm knocked a tree down and totaled my home on the hill.–I’ve have to live in hotels, rentals, my RV and now back in the home that insurance finally fixed–I couldn’t refinance after my 1yr because the contractors were jerks and went on vacation and left my house with nothing but a few walls left (it was a total rebuild)…no bank will refinance if an appraiser can’t find a house to appraise. By the time I finally had a house again, and was signing the last page on my refinance loan 4months later— it was too late–the bottom had fallen out on the real estate market—even my good credit didn’t matter—no refinance—no one was loaning. That was 15months ago. I haven’t had a good night’s sleep since then. I work full time and still have to drum up double what I make every month to pay that subprime mortgage loan each month. It is killing me. And of course just when I really need my roommate (male companion) to come through for me and pay more than his pathetic tiny amount each month…he has no work and no money at all) The only way out is to sell. And the contractors screwed up and left a zillion things that weren’t done so I have had to do that too. Plus sell everything of value I owned. I’ve been to every counseling service looking for help and there is no one out there who can help me save the home…..all the same advice–dump the deadbeat guy and sell the house. So I am.
I tell you this cuz I’m angry everyone thinks all those people who took out subprime loans were greedy and bought more than they can pay for and now we’ve ruined it for everyone else. I’m angry there is no help out there for someone like me who has worked my whole life and now my credit is ruined (can’t pay hardly anything except that huge mortgage–I pay more than a house that’s for rent right now near Bill Gates mansion on Lake Washington–it rents for 2950.00mo….my mortgage is 3400.00 mo! for a tiny 2b 1ba 1150sq ft house) So tell everyone there are some that took those crappy loans for a short term catastrophic event and worked VERY hard to have great credit to get out of the loan–but couldn’t because of bad misfortune, not greed.

You just told them yourself. Gosh, I’m sorry. You have had a horrible series of events. But you are here, and you are a survivor, and for that I give you a great deal of credit. It sounds like time to just live each day, and to do your best to avoid looking too far forward. And remember—once things are gone, there is nothing they can take from you anymore. I know it hurts, but try to avoid feeling like a bad or evil or worthless person. You have done great things to last through all of this—that is your heroic record.

Then what…My sister got cancer, my dad died, a coyote got my cat that was the love of my recent life.
I GIVE UP. I’M GOING HOME to my mom in Iowa. She’s all alone now, and I need to quit whining about myself and help her so I feel useful in this life I have. My last day at my airline job is 31Aug09. I need to be off this suboxone no later than November. I hope to use the first part of Sept to get over it. I hope your tapes show a way that is painless—if my house does sell I have no idea where I’ll be in the interim before moving to Iowa.

Why do you have to stop the Suboxone? Pretty much all of my patients have jobs, and many get drug tested—it hasn’t shown up yet. If it does, tell them the truth—that you are taking it for chronic pain because it doesn’t ‘mess up your thinking’ like ‘REAL’ pain pills do.

There is NO painless way to withdraw in a few weeks. My tapes recommend reducing very, very slowly over a number of months, to a very low, microgram dose.

Sorry for the ramblins…if you dont read it that’s ok…it’s just another hard-knock story.

You only asked about Talwin..it SUCKS===dont recommend it. That’s probably why it’s hard to find at most pharmacies–no one uses it. I can’t go thru any w/d right now–I just finished the interior floors in my house–it’s almost ready to sell–took me 15months to do all the stuff that didnt get done by contractors–so I HAVE TO FOCUS on selling this place now.
What do I want—I will get your tape for w/d from suboxone. And I need to learn to let go of anger, regret and fear. Easier said than done. Do I use positive repetition to retrain my thoughts to quit worrying so much?

That would be ‘CBT’, and another long process. For now, you take one day at a time and do a daily inventory at the end of each day, reflecting on the good things you have done and giving yourself some credit. If you REALLY need to be off Suboxone by September, the time to start weaning is now—but you do it so slowly that the w/d is very small. Ten percent reduction every couple weeks.

I truly wish you the best. I will send you a link to download the tapes without charge; maybe that will be the start of your luck turning around.

Tapering Suboxone

I am placing a new link in the Blogroll to a site that discusses tapering Suboxone.  I want to be clear that in my opinion, an opiate addict’s safest place is on Suboxone.  Many opiate addicts also find that on Suboxone they experience less mood variability, less irritability, and less anxiety;  I wonder if those symptoms represent forms of craving for those individuals.
I don’t see a ‘disease theory of addiction’;  rather I see very clearly that opiate dependence IS A DISEASE  (maybe we need to run a campaign:  It’s a disease, stupid!).  For hypertension, people take their medication and spend no time worrying about whether they are ‘living a life free from beta-blockers’.  Seeing that the people who judge addicts as ‘weak’ are idiots, I don’t understand the push to ‘get off Suboxone’.
If you are having side effects from Suboxone, please talk to your doctor.  If you are having random urges to stop Suboxone, at least consider the possibility that on some level you are setting things up to use again… and talk to your doctor.  If you have taken Suboxone for a long-enough period of time to make new, non-using friends, to lose all of the phone numbers, to get a good job, to come to terms with the family issues caused by your addiction– and if you can take Suboxone once per day without giving in to urges to take a bit more or to dose twice per day– AND if you have a plan to replace Suboxone with a recovery program– then maybe you are ready to taper off Suboxone.  In that case… talk to your doctor!!
I will of course put in a plug for a tape that I made, that discusses when and how to stop Suboxone– it is for sale on the right side of this page, or at SoberAfterSub.com.
If you are making a sound decision based on some good, sober thinking, check out the web page SuboxoneTaper.com.  It is relatively new, but I like the attitude of the writer– admittedly because he seems to think and write like me!  He comes across as cocky and angry… and I realize that I write like that as well.  Let there be no mistake– I have connections to some other web sites out there, but I have no connection to this one, and I don’t know the writer.  So if he suddenly gets in trouble for selling a Senate seat, I had nothing to do with it and I have nothing to say about it!!